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TBS Youth Programming Registration Form
Please complete this online form and let me know immediately if there are any changes. It will be retained and brought to all off-site events for your child’s safety and security. Upon completion of this form you and your child will receive an emailed copy of Our Covenant of the Community for TBS B’rit Kehillah – ברית קהילה. Please read through this with your child and include a hard copy signed with your dues.
Registration for 2017-2018: ASAP
For additional information and/or questions, please contact Andrea Seidenberg, Youth Engagement Director at
Participant Information (Please complete one form for each child) Child's Name/Nickname(s), Address, Date of Birth, School, Grade, Cell Phone & Email Address
Social Media is used to advertise our events. Please provide the following information if you would like to receive information. Facebook, Instagram, Twitter
Parent/Guardian Information-Name(s), home phone, cell phone, email address(s)
Medical Information: Insurance Company, ID #, Policy #.
Please list any special needs, medical conditions, allergies, medications, or other circumstances of which we should be aware.
Emergency Contact Information: Please provide the names and phone numbers of two additional relatives or friends who may be contacted in an emergency if you cannot be reached. These should be people who are comfortable taking responsibility for your child if you are not available.
Legal Information: I (Parent/Guardian) acknowledge that I have been/will be informed of the planned activities and the provisions for my child’s involvement, and I consent to my child’s participation in these activities. I hereby authorize the Temple Beth Sholom Youth Engagement Director and her representatives to hospitalize or secure proper medical treatment for my child in the event that I cannot be reached in an emergency. I will not hold my Youth Engagement Director, designated representatives or employees liable for any harm that may come to my child during or in transit to/from any TBS-endorsed activities.When necessary, I further consent to my Youth Director arranging transportation for my child to activities, either by bus, train, or in a private car driven by a parent or parent-designated adult of at least 18, and I hereby give permission for my child to ride in such vehicles. *Please provide your signature below.
Publicity: I am aware that pictures of my child may be taken at youth events and I give permission for these photos to be used for publicity and advertising of TBS Youth Group or future youth activities.
Yes, I give permission.
No thank you. I do not give permission for photos to be taken of my child.
TBS Youth Programming Dues Cost: $54.00 Cash or checks made payable to Temple Beth Sholom Youth Group. Dues can be mailed to TBS or put in the Youth Group Mailbox Attn: Andrea Seidenberg.
Parent/Guardian Signature and Participant Signature & Date
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